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Key messages
Abdominal pain (see Section 9.6.1)
Migraine (also see Section 9.6.5)
1. Triptans or phenothiazines (prochlorperazine, chlorpromazine) are effective in at least 75%
of patients presenting to the emergency department with migraine (U) (Level II).
Local anaesthesia
2. Topical local anaesthetic agents (including those in liposomal formulations) (N) (Level I) or
topical local anaesthetic‐adrenaline agents (N) (Level II) provide effective analgesia for
wound care in the emergency department.
3. Femoral nerve blocks in combination with intravenous opioids are superior to intravenous
opioids alone in the treatment of pain from a fractured neck of femur (S) (Level II).
The following tick box represents conclusions based on clinical experience and expert
opinion.
To ensure optimal management of acute pain, emergency departments should adopt
systems to ensure adequate assessment of pain, provision of timely and appropriate
analgesia, frequent monitoring and reassessment of pain (U).
9.10 PREHOSPITAL ANALGESIA
The above section (9.9) considered management of acute pain in patients admitted to
emergency departments. However, many of these patients will also have required prehospital
pain relief when under the care of paramedic or medical retrieval teams. While the term
‘prehospital’ is also used to cover a greater variety of prehospital locations, it is beyond the
scope of this document to look at pain relief administered in more complex situations such as
war or disaster settings.
Many of the patients transported by ambulance services or retrieval teams will have pain that
CHAPTER 9 the prehospital environment that will impact on the way that the pain can and should be
requires treatment prior to and during transport. However, there are some specific features of
managed. The environment is often uncontrolled, there may well be a shortage of assistance,
light, shelter and suitable equipment, and the patient is often in the acute or evolving stage of
their condition, which may change rapidly.
Provision of prehospital analgesia is important, given that pain in the prehospital setting is
common and that moderate or severe pain is present in at least 20% of patients (McLean et al,
2002), nearly one‐third of all injured patients and over 80% of those with extremity fractures
(Thomas & Shewakramani, 2008). Yet the proportion of patients given analgesics (opioid or
inhalational) prior to transfer to an emergency department varies significantly. ‘Unnecessary
pain’ was the second most common type of injury in 56 of 272 claims against ambulance trusts
in the United Kingdom between 1995 and 2005 (Dobbie & Cooke, 2008).
One survey of 1073 adult patients with suspected extremity fractures showed that just
18 were given any analgesia and only 2 received morphine (White et al, 2000 Level IV). A later
survey showed that only 12.5% of patients with isolated extremity injuries received any
prehospital parenteral pain relief (Abbuhl & Reed, 2003 Level IV). Another study reported
prehospital opioid administration in 18.3% of patients with lower extremity fractures; however
older patients and those with a hip fractures were less likely to be given analgesia prior to
arrival in the emergency department (McEachin et al, 2002 Level IV). In contrast, another group
294 Acute Pain Management: Scientific Evidence
